Rest: Is it the best medicine for concussion?


The 4th International Consensus Statement on Concussion in Sport indicates that cognitive and physical rest is the cornerstone of acute concussion treatment. While acknowledging that the supporting evidence is sparse, rest is recommended for 24 to 48 hours post-concussion. The period of rest is suggested to encompass reduced or limited cognitive, physical and social activities by restricting school attendance, academic work, electronic usage and exercise. People are expected to rest until all of the concussion symptoms have gone.  For many reasons, this recommendation is inconsistent with many principles of sport and rehabilitative medicine. Rest has many negative consequences for people. Pain, fatigue, abnormal metabolic states, stiffness, weakness and mood disorders are all associated with prolonged rest. In general, the sports medicine movement began to help individuals maintain their function by avoiding rest, and its negative consequences. The prescription of rest is becoming a controversial area in the management of concussion. Concern exists that, not only is rest not helpful, but that it may actually predispose patients to delayed recovery and an increased risk of chronic post–concussion symptom reporting.

One of the problems with “rest until the symptoms are all gone”, is that healthy people have concussion symptoms all the time.  Fatigue, irritability, sadness, sleeping troubles, and headache are present in many people from other disorders.  So the target of the “rest intervention” is a problem, as the symptoms are non-specific.  Another problem is that there are very few acceptable scientific papers that indicate that rest is actually helpful.  We use the term that rest for concussion is not “evidence based”.  What I have observed clinically, is that people who are advised to remove themselves from school, work and sport, often experience predictable negative consequences.  Isolation, sadness, a lack of the positive environmental stimuli from team and social activities can increase the risk for a depressed mood.

Several recent academic papers have indicated that rest can delay recovery after concussion. Buckley at el. published a paper in the Journal of Head Trauma Rehabilitation in 2016. Their article was entitled “Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time”. The authors studied 50 individuals, 25 of whom were concussed patients in the “no rest” group; they were not provided with any cognitive rest accommodations. They were not excused from attending classes or team meetings and were not excused from performing homework assignments, tests or projects. They were not allowed to participate in athletics or workouts while symptomatic. The “rest group” was prohibited from all of the aforementioned activities. The authors found that the group who did not rest was able to recover more quickly than the rest group. The “no rest” group was asymptomatic significantly earlier in their recovery. There was no difference between the groups in their ability to perform balance testing or other cognitive functions. The authors noted that removal from academic and team functions may increase the risk of depression, and decrease physical capacity, as the patient is removed from their regular activities of daily living. They indicated that just three days of bed rest reduces exercise performance and the neuro-hormonal response to subsequent exercise. Fatigue and depressive symptoms emerge within seven days of stopping exercise.

Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time.
Buckley TA, Munkasy BA, Clouse BP.
J Head Trauma Rehabil. 2016 Jul-Aug;31(4):233-41.

Another article published in the journal Pediatrics in 2015 also evaluated the prescription of rest after acute concussion in a randomized, prospective study. Ninety-nine patients were enrolled in the study. After attending an emergency department after a concussion, subjects were randomized to a strict rest group for five days versus a usual care group, which had one to two days of rest followed by a stepwise return to activity. The individuals who were rested actually reported more daily post-concussion symptoms and slower symptom resolution than the group who was allowed to return to more usual activities after one to two days.

Benefits of strict rest after acute concussion: a randomized controlled trial.
Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T.
Pediatrics. 2015 Feb;135(2):213-23.

Another paper published in the American Journal of Sport Medicine in 2016 by Howell et al, indicated that physical activity level after concussion did not influence the duration of symptoms.

In general, the medical literature seems to be confirming that physical and cognitive rest is potentially harmful to individuals by delaying recovery after a concussion. This in no way indicates that individuals are allowed to have any potential head shake or head trauma in the critical first week after a concussion. However, removing oneself from one’s normal milieu of school and/or work can be potentially harmful.

This brings us back to the seven R’s of concussion management. The seven R’s of concussion management are as follows:


  1. Reassure the patient about the good prognosis of concussion: up to 90% will recover within seven to ten days.
  2. Refrain from risky sport and work. Do not put yourself in harm’s way. No head shake.
  3. Reduce symptom producing activities such as exercise and rapid head movement.
  4. Return to school and work as soon as possible.
  5. Re-activate yourself through safe exercise below the level of your symptoms. Activity such as walking would be a great place to start.
  6. Referral for treatment of your neck and vestibular system. There is evidence that treatment of the cervical spine and the vestibular system can help you feel better faster.
  7. Recycle principles of multi-disciplinary chronic pain management for those who have delayed recovery. Multi-disciplinary care can help to minimize your suffering.